The Manual of Trigger Point and Myofascial Therapy

26 Chapter 5 Figure 5-1. Examples of the referred pain pattern ( R P P) Figure 5-2. T he pilomotor reflex is one of the autonom­ of the sternocleidomastoid muscle. T he trigger point ic disturbances that may be present near the area of a refers pain to distal locations, as illustrated in these pho­ myofascial trigger point (reprinted with permission from tographs, which is characteristic for this muscle. Gunn C. Treating Myofascial Pain: Intramuscular Stimulation (IMS) for Myofascial Pain Syndromes of Neuropathic Origin. Seattle, Wash: University of Washington; 1989). the sacroiliac joint may be disturbed, causing an abnormal normal muscle flow of proprioceptive input. The contraction rate (time injured muscle of recruitment of the maximum number of motor units required for contraction) will slow down, making the neu­ t1 1\\101� 12 romuscular function slower and exposing the muscle to danger of future injury (Figure 5-3). CONTRACTION RATE EDEMA AND CELLULITE Figure 5-3. A slower contraction rate will create a slow- er recruitment of motor units. Due to the decreased blood circulation and accumula- tion of the products of cellular metabolism, the area may PHYSICAL FINDINGS develop local edema. This can be easily identified using the \"matchstick test.\" Skin indentations produced by the acute instrument will remain for a prolonged period of time, indicating local edema (Figure 5-4). Presence of cel- lulite is not uncommon (Figure 5-5). DERMATOMAL HAIR Loss TAUT BAND In cases of myofascial trigger points present in the The taut band includes those muscle fibers that are paraspinal muscle, Gunn3 reported hair loss to the corre­ myofascially involved (Figure 5-7). Rubbing across these sponding dermatome depending on the spinal level fibers gives a rope-like sensation. The myofascially involved (Figure 5-6). involved fibers include local areas with overshortened sar­ comeres as well as overstretched areas. The overshortened SLEEP DISTURBANCES sarcomeres reflect the focus on and around the myofascial trigger point, while the overstretched ones mpresent the Patients will often complain of lack of sleep due to distant areas of the same muscle fibers. After the trigger pain, numbness, burning sensation, or other disturbances. point is resolved, the taut band may disappear. Patients usually assume an antalgic, temporarily comfort­ able position during the night that puts the muscle in a TENDER AND PAINFUL NODULES shortened position. This may cause further activation of myofascial trigger points (through overshortening) and When palpating along the taut band, the entire area further loss of flexibility. will demonstrate some tenderness; however, the locus

Clinical Symptoms and Physical Findings 27 Figure 5-4. Edema may be present near the area of a Figure 5-5. Cellulite may be present near myofascial trigger point due to circulatory problems the area of a myofascial trigger point (reprinted with permission from Gunn C. Treating (reprinted with permission from Gunn C. Myo(ascial Pain: Intramuscular Stimulation (IMS) (or Treating Myo(ascial Pain: Intramuscular Stimu­ lation (IMS) (or Myo(ascial Pain Syndromes o( Myo(ascial Pain Syndromes o( Neuropathic Origin. Seattle. Wash: University of Washington; 1989). Neuro-pathic Origin. Seattle. Wash: University of Washington; 1989). PATIENT PAIN RECOGNITION Ischemic compression or needle insertion on the myofascial trigger point may exhibit pain or other sensa­ tion that is recognizable by the patient as similar to the main symptom he or she experiences. Patient pain recog­ nition is one of the essential criteria for the diagnosis of a myofascial trigger point. LOCAL TWITCH RESPONSE Figure 5-6. Dermatomal hair loss may be Local twitch response (LTR) is produced through a present in cases of myofascial trigger points in local depolarization of the muscle membrane of the the paraspinal muscles (reprinted with per­ myofascially involved fibers (taut band area). It can be mission from Gunn C. Treating Myo(ascial Pain: elicited either through pincer snapping palpation across the taut band (see Figure 5-7) or through a needle inser­ Intramuscular Stimulation (IMS) (or Myo(ascial tion. LTR may have a therapeutic effect by causing meta­ bolic changes in the area. Multiple LTRs are induced Pain Syndromes o( Neuropathic Origin. Seattle. through the trigger point dry needling technique and Wash: University of Washington; 1989). seem to have a positive effect on the resolution of the myofascial trigger point. LTR through snapping palpation directly on and around the myofascial trigger point will can be useful in the release of persistent, unresolved trig­ exhibit nodularity and exquisite pain. Progressively ger points. increasing pressure on the nodule will elicit the RPP and possibly the sign of patient pain recognition. LIMITED RANGE OF MOTION Due to the abnormal tension and tenderness present in the taut band, the myofascially involved muscle will exhibit limitation in range of motion, especially at the end range of movement. Muscle stiffness and tightness are very common, especially after hours of prolonged immo­ bility, such as in the early morning hours.

28 Chapter 5 Taut (palpable) bands in muscle Relaxed muscle fibers Local twitch response Normal resting length of muscle Local Figure 5-8. Length-tension relationships in contracting 11111 twitch muscle. The graph shows the amount of tension generat­ ed by a muscle compared with its resting length before � of band contraction begins. T he inserts of the sarcomeres show the amount of overlap between thick and thin filaments at B each resting muscle length. If the muscle is too long, the filaments in the sarcomere barely overlap and cannot Figure 5-7. Palpation of a taut band. Rolling the band form as many crossbridge links (e). If the muscle begins its quickly under the fingertip (snapping palpation) at the contraction at a very short length, the sarcomere cannot trigger point often produces a local twitch response shorten very much before the myosin filaments run into (reprinted with permission from Travell J G . Simons D G. the Z disks at each end (a) (reprinted with permission Simons LS. Myofascial Pain and Dysfunaion: The Trigger Point from Silverthorn D. Human Physiology: An Integrated Manual-Upper Half of Body. Baltimore. Md: Williams & Approach. Upper Saddle River. NJ: Prentice Hall; 1998). Wilkins; 1999). muscle will cause local ischemia resulting in decreased MUSCLE WEAKNESS energy sources. This may affect muscle performance. Muscle guarding due to local or referred pain can produce Muscle weakness is commonly seen in patients with antalgic movement and subsequently poor muscle per­ myofascial trigger points, and there are various possible formance. Research demonstrates that muscles with sources to account for it. Usually the manual muscle test myofascial trigger points fatigue more rapidly and become will result in half to one grade lower in the involved mus­ exhausted sooner than normal muscles. I ,2 Muscle imbal­ cle as compared to the rest of the uninvolved muscles of ances may develop, with various muscles prone to inhibi­ the same side or the muscles of the uninvolved side. The tion and therefore weakness, while others are prone to length-tension relationship curve (Figure 5-8) explains excitation and therefore tightness. how overshortened sarcomeres allow the formation of a lesser number of cross bridges between actin and myosin POSITIVE STRETCH SIGN filaments. This will result in a decrease in the tension that the muscle can possibly develop. It is clinically evident Positive stretch sign (PSS) is defined as any pain of that application of myofascial trigger point therapy fol­ mechanical or neural origin that develops in the joint dur­ lowed by myofascial stretching exercises can improve ing myofascial stretching. Passive or active stretching of a muscle strength by promoting lengthening of the sarcom­ muscle with active myofascial trigger points, especially to eres and therefore creating the potential for formation of the end of range, is inhibited. The increased tension of a larger number of cross bridges between the myofila­ the taut bands will inhibit the muscle to extend to its full ments. In addition, spasm of the myofascially involved range and will affect proper joint mechanics. The result­ ing movement will be compromised, with altered and abnormal joint mechanics. This abnormal movement will create stresses to the joint, resulting in pain. When PSS is elicited during myofascial stretching, it is an indication that pushing through to further stretching could be harm-

Clinical Symptoms and Physical Findings 29 fu!. Returning the muscle to its resting position and apply­ REVIEW QUESTIONS ing additional trigger point therapy (ischemic compres­ sion or other techniques) will further decrease the activi­ I. A microtrauma may occur only through a high­ velocity movement. ty of the trigger point and will allow us to achieve a True False greater range of motion at this time. 2. The reason for local pain in the area of a trigger Alternating back and forth between trigger point ther­ point is the presence of Ca2+. apy and myofascial stretching exercise seems to be the True False most effective approach to treatment. PSS guides the cli­ nician to decide on the extent of myofascial stretch that 3. Myofascial trigger points refer pain to distal or is appropriate at a given time (eg, treating a patient with proximal locations in specific patterns characteris­ a diagnosis of shoulder impingement and active myofas­ tic for each muscle. cial trigger points on the subscapularis [SSe] muscle). True False After the application of ischemic compression to the sse muscle, the clinician follows with the appropriate myofas­ 4. Overstretched sarcomeres reflect the locus on ciaI stretch. In this case, achieving full abduction of the and around the myofascial trigger point, while shoulder is desired. At about 70 degrees of shoulder overshortened ones represent the distant areas of abduction, the patient complains of pain at the top of the the same muscle fibers. acromion (impingement). This type of pain is defined as a True False PSS because it was developed during the stretching action of the treatment. Apparently, the pain has a mechanical 5. Patient pain recognition and referred pain patterns origin and derives from improper joint mechanics of a have identical definitions. myofascially involved tight sse. Bringing the muscle True False back to a relaxed position and working further with ischemic compression on the trigger point will allow us to 6. It is possible that patient pain recognition and repeat the stretch without eliciting pain (PSS) until we referred pain patterns extend to exactly the same reach 85 degrees of shoulder abduction. We continue back area. and forth, alternating between ischemic compression and True False stretching, several times, noticing that as the trigger point activity decreases we are able to achieve a further increase 7. Local twitch response is produced through a local in the range of motion. To not pay attention to the PSS depolarization of the muscle membrane of the and stretch the muscle aggressively regardless of joint pain myofascially involved fibers. can be counterproductive to the treatment and harmful to True False the patient. PSS should not be confused with local muscle soreness and tenderness from the referred pain pattern. If local muscle soreness develops, one may use the \"spray and stretch\" technique and continue within the patient's tol­ erance limit. 8. Presence of myofascial trigger points in a muscle has no effect on the range of motion, muscle strength, and flexibility. True False 9. Pain of mechanical or neural origin that develops in the joint during myofascial stretching is defined as _________________

30 Chapter 5 REFERENCES 10. During the application of trigger point therapy 1. Headley B. Assessing surface EMG. Rehabilitation (digital compression of the trigger pOint) the Management. 1992;5:87-91. patient complains of pain and states \"this feels like the kind of pain I usually have.\" Would you define 2. Headley B. Evaluation and treatment of myofascial pain this as: syndrome utilizing biofeedback. In: Clinical EMG for A. Positive stretch sign Surface Recordings. Nevada City. Nev: Clinical Resources; B. Patient pain recognition 1990:235-254. C. Referred pain pattern D. None of the above 3. Gunn Cc. Treating Myofascial Pain: Intramuscular Stimulation OMS) for Myofascial Pain Syndromes of I I. During the application of myofascial stretching of Neuropathic Origin. Seattle. Wash: University of the iliopsoas muscle. the patient complains of Washington; 1989. slight soreness in the anterior thigh by the inser­ tion of the iliopsoas. According to the authors. this is a: A. Positive stretch sign. Stretching must stop. Do more digital compression and repeat stretch­ ing. B. Patient pain recognition. Stop treatment imme­ diately. C. Pain due to muscle stretching. Use spray and stretch and continue within the patient's limits of tolerance. D. None of the above.

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Chapter 6 hile there is no one specific mechanism clearly 4. Sympathetic nervous system activity: Sympathetic fibers release nociceptive sub­ Widentified as responsible for the referred pain stances (prostaglandins) that sensitize primary pattern of myofascial trigger points, there are afferent nerve endings in the region of a trigger various possible mechanisms that may share responsibili­ point. ty. 5. Convergence or image projection at the A pain stimulus to be perceived by the sensory cortex supraspinal level: Convergence of pain pathways is transformed at least four times on at least four levels: at a supraspinal, thalamic level. 1. The receptor site converts the stimulus into a Quintner and Cohen3 challenge the premise that a nerve impulse. myofascial trigger point gives rise to a referred pain pat­ tern. They suggest that \"all myofascial pain syndrome 2. The spinal cord level. phenomena are better explained as secondary hyperalge­ 3. The network structures between the spinal cord sia of peripheral nerve origin.\" and the sensory cortex (thalamus). Simons supports that one of the mechanisms responsi­ 4. The sensory cortex itself. ble for referred pain is the peripheral sensitization of noci­ In 1969, Selzer and SpencerI.2 postulated five different ceptors.4 The presence of bradykinin, E-type mechanisms to explain referred pain: prostaglandins, and 5-hydroxytrimptamine near the 1. Peripheral branching of primary afferent axons: active loci can create sensitization effects contributing to the referred pain mechanism. A recent study using the The brain misinterprets messages originating animal model of rabbit tissue demonstrated that various from nerve endings in one part of the body if phenomena at the spinal cord level may be related to the originating from another part of the body. referred pain pattern.4,s Specifically, the study demon­ 2. Convergence-projection: A single nerve cell in strated that pain stimulation of the receptive field of a the spinal cord receives nociceptive stimuli both nociceptor axon in a muscle resulted in the appearance of by internal organs and by the skin and/or mus­ additional receptive fields in the same extremity. The sen­ cles. The sensory cortex cannot distinguish sitivity of the dorsal horn cell to noxious stimuli increased whether the information had a visceral or cuta­ to include additional receptive fields. These studies impli­ neous origin and misinterprets the nociceptive cate the spinal cord in referred pain pattern mechanisms. signal. 3. Convergence-facilitation: Cutaneous sensory Hong et als,6 found that when a needle penetrates the afferent activity; if insufficient quantity to myofascial trigger point, referred pain is elicited 87.7% of excite the spinothalamic tract, it is facilitated by the time, while palpation will elicit referred pain only strong abnormal visceral afferent activity inter­ 53.9% of the time. preted as pain.

34 Chapter 6 REVIEW QUESTIONS REFERENCES I. T he presence of bradykinin, E-type prostaglandins, 1. Selzer M, Spencer WA. Convergence of visceral and cuta­ neous afferent pathways in the lumbar spinal cord. Brain and S-hydroxytrimptamine near the active loci can Res. 1969;14(2):331-348. create sensitization effects contributing to the 2. Selzer M, Spencer WA. Interactions between visceral and cutaneous afferents in the spinal cord: reciprocal primary referred pain mechanism. afferent fiber depolarization. Brain Res. 1969;14(2)349-366. True False 3. Quintner ]L, Cohen ML. Referred pain of peripheral nerve 2. Research has demonstrated that various phenom­ origin: an alternative to the \"myofascial pain\" construct. Clin] Pain. 1994;1O:243-5l. ena at the spinal cord level are not related to the 4. Travell JG, Simons DG, Simons LS. Myofascial Pain and referred pain pattern. Dysfunction: The Trigger Point Manual-Upper Half of Body. True False Baltimore, Md: Williams & Wilkins; 1999. 3. Palpation may elicit a referred pain pattern more 5. Hong CZ, Simons DG. Pathophysiologic and elecrrophysi­ frequently than needle insertion. ologic mechanisms of myofascial trigger points. Arch Phys Med Rehabil. 1998;79:863-72. True False 6. Hong CZ, Kuan TS, Chen JT, Chen SM. Referred pain elicited by palpation and by needling of myofascial trigger points: a comparison. Arch Phys Med Rehabil. 1997;78:957- 60.

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Chapter 7 here are several ways to classify myofascial trigger SATELLITE TRIGGER POINT Tpoints. Here we adopt the most frequently used in Satellite trigger points (Figure 7-1) may develop in the the literature and clinical practice. same muscle where the primary (main) trigger point is, in ACTIVE TRIGGER POINT other muscles within the referred pain pattern of the pri­ mary trigger point, or in synergistic muscles. The satellite An active myofascial trigger point produces pain with­ trigger point usually resolves once the main trigger point out digital compression. It is very tender upon palpation; is resolved, without any additional intervention. it produces a characteristic referred pain pattern for the muscle, either with ischemic compression or without; it In their most recent text, Simons and Travell1 make a impedes muscle flexibility; it produces muscle weakness; distinction between central and attachment trigger and it may elicit a local twitch response with compression points. They are defined below. or needle stimulation. CENTRAL MVOFASCIAL TRIGGER POINT LATENT TRIGGER POINT A central myofascial trigger point is closely associated with dysfunctional endplates and is located near the cen­ A latent myofascial trigger point is usually silent­ ter of muscle fibers. without causing any spontaneous pain. However, it is ten­ der upon palpation, it may produce a referred pain pattern ATTACHMENT TRIGGER POINT only with the application of ischemic compression, it impedes muscle flexibility, it produces muscle weakness, An attachment trigger point (see Figure 7-1) is a trig­ and it may elicit a local twitch response with compression or needle stimulation. Latent myofascial trigger points ger point at the musculotendinous junction and/or at the may exist in the muscle for years following recovery from osseous attachment of the muscle that identifies the an injury. An active trigger point that was never treated enthesopathy caused by unrelieved tension characteristic or was improperly treated may become latent at a chronic of the taut band that is produced by a central trigger stage. Latent trigger points may be reactivated and point. become active with microinjury/microtrauma or with a macrotrauma.

38 Chapter 7 REFERENCE 1. Travell ]G, Simons DG, Simons LS. Myofascial Pain and Dysfunction: The Trigger Point Manual-Upper Half of Body. Baltimore, Md: Williams & Wilkins; 1999. Figure 7·1. Classification of myofascial trigger points. REVIEW QUESTIONS I. An active myofascial trigger point produces pain without digital compression. True False 2. A latent myofascial trigger point is usually active and causes spontaneous pain. True False 3. A latent myofascial trigger point has no effect on muscle flexibility and does not produce muscle tightness. True False 4. An active trigger point that was never treated or was improperly treated may become latent at a chronic stage. True False 5. Latent trigger points may be reactivated with microinjury/microtrauma or with macrotrauma. True False 6. A myofascial trigger point that is closely associat· ed with dysfunctional endplates and is located near the center of a muscle fiber is defined as a ___ trigger point.

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Chapter 8 n important component in the diagnosis of trigger 1. \"Recalling the time of your injury, please describe or show me specifically how you fell.\" Apoint myofascial syndrome, especially when a decision must be made regarding the appropriate 2. \"Recalling the exact way you move your wrist at muscle to treat, is the biomechanics of the injury. One work, please show me the specific movements must consider the specific mechanism that may be respon­ involved.\" sible for the injury. 3. \"Recalling the exact way you sit while you watch tel­ Using the referred pain pattern as the sole criterion to evision, please show me specifically how you sit?\" identify the muscle responsible for the dysfunction will produce inaccurate results because the referred pain pat­ The least complicated cases to determine the biome­ terns of several muscles overlap each other. Taking the chanics of injury are those that are the result of a high­ patient's history and asking appropriate questions that will velocity movement, such as sports injuries, sudden falls, lead to identifying the possible mechanism of injury and motor vehicle accidents. Patients injured through becomes very important. This process will help to piece these mechanisms will easily recall the specific way they together the diagnostic puzzle and, through deductive rea­ fell or were injured and the position their body assumed soning, arrive at correct conclusions regarding proper during that injury. However, injuries are not always the treatment. result of a high-velocity movement. Repetitive motion injuries, as well as injuries through stress positions, are Components that must be identified: very common. Manual laborers, musicians, and athletes * Direction of external force applied (if the injury engage in activities that require repetitive movement. Work stations that are not ergonomically correct will add involved an external force). further stress to joints and muscles. * Relative position of the body during the injury. * Specific movement that the body followed after The clinician must always ask the patient to specifical­ ly demonstrate the repetitive movement that may have application of the external force. caused the injury. Positions that put the muscles and * Specific postural position that the patient usually joints under stress should also be considered. Postural and skeletal asymmetries, faulty posture, habitually biome­ assumes (if it is a postural dysfunction). chanically poor body positions, and stressed body posi­ * Direction of habitual or repetitive movement (if it is tions over prolonged time may cause microtrauma and thus myofascial trigger point syndrome. This last category a repetitive motion injury). is the most challenging to obtain information from the * Mechanics of the pelvis and spine in cases of skeletal patient regarding the biomechanics of injury because most of the time the patient is not conscious of certain posi­ asymmetries. tions or motions that caused the problem. * Positional and functional anatomy of the feet in cases of faulty feet mechanics. Careful inspection and observation may give hints regarding the biomechanics of injury; however, appropri­ ate questions should be asked:

42 Chapter 8 REVIEW QUESTIONS I. The referred pain pattern is the sole criterion to identify the muscle responsible for the myofascial dysfunction. True False 2. Taking the patient's history and asking appropriate questions becomes very important and will lead to identifying the possible mechanism of injury. True False 3. Postural and skeletal asymmetries, faulty posture, habitually biomechanically poor body positions, and stress body positions over prolonged time may cause microtrauma and thus myofascial trig­ ger point syndrome. True False

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Chapter 9 here are several steps that one must consider in the The lack of consistency and use of vague expressions cre­ ates a problem in accurately defining terms and coming to Tdiagnosis of myofascial trigger point syndrome. an agreement about what each of these terms represents. Many times, the myofascial diagnosis may be sec­ In the authors' opinion, the most comprehensive term ondary to the patient's problem. Physical and occupation­ that has been used in the literature to describe the symp­ al therapists, as well as doctors of physical medicine and toms caused by a myofascial trigger point is myofascial trig­ rehabilitation, frequently evaluate and treat patients who ger point syndrome (which we will adopt for this text). This have been referred to them by a primary care physician, term was introduced by David Simons, MD and we an orthopedist, a rheumatologist, a dentist, a podiatrist, encourage clinicians and researchers to use this term in a and others. Frequently, the clinician who initially evalu­ consistent manner. Therefore, we use the name of the ated the patient may have established a nonmyofascial­ muscle that is myofascially involved followed by myofas­ type diagnosis and ignored a possible primary or secondary cial trigger point syndrome. Examples include iliopsoas myofascial component to the dysfunction. Careful evalu­ myofascial trigger point syndrome, infraspinatus myofas­ ation and assessment of the patient will frequently reveal cial trigger point syndrome, etc. that a cervical radiculopathy may have an associated ster­ nocleidomastoid and scalenus myofascial trigger point RECOMMENDED CRITERIA TO IDENTIFY syndrome; or a patient with pain in the heel and a primary diagnosis of inflammation due to a heel spur may have an ACTIVE AND LATENT MYOFASCIAL associated tibialis posterior, soleus, and/or quadratus plan­ tae myofascial trigger point syndrome. Therefore, it is TRIGGER POINTS important to further evaluate patients from a myofascial point of view and decide whether the myofascial compo­ Studies by various researchers were reviewed regarding nent is a consequence of the primary diagnosis or a cause their validity and interrater reliability for accurate identi­ of it. In the latter scenario, the myofascial diagnosis fication of myofascial trigger points.I-7 Hsieh et al4 report­ should become the primary one. ed poor interrater reliability in the identification by pal­ pation of characteristics of myofascial trigger points; how­ DIAGNOSTIC TERMS ever, their interpretation of data and of the meaning of the Kappa values has been strongly challenged.2 Gerwin There are various expressions that can be used to et a12,3 conducted an organized and detailed study and describe a myofascial diagnosis. Some of them utilize the managed to obtain impressive Kappa values for the vari­ terms myofascial dysfunction, myofascial syndrome, regional ables tested, indicating excellent reliability measures. myofascial syndrome, myofascial pain syndrome, and others. Table 9-1 presents the variables tested and their results.

46 Chapter 9 Table 9-1 INTERRATER RELIABILITY OF EXAMINATION OF TRIGGER POINTS3.13 Characteristic Examined Kappa Value Spot tenderness 0.84 Patient pain recognition 0.88 Palpable taut band 0.85 Referred pain pattern 0.69 Local twitch response 0.44 Mean score 0.74 Based on the variables studied by Gerwin et al2,3,8,9 and etration at the area of the active locus. This area may suggestions made by Travell and Simons,10.14 we adopt the include the inunediate area of the trigger point as well following essential and confirmatory criteria for the accu­ as the immediate area around it. rate identification of latent and active myofascial trigger 3. Referred pain pattern: An RPP characteristic for the points. specific muscle may be elicited during digital com­ pression on the area of the active locus. ESSENTIAL CRITERIA 4. Spontaneous electromyographic (EMG) activity: Presence of spontaneous EMG activity may occur 1. Palpable taut band: If the muscle is accessible, palpate when an EMG needle slowly approaches the area of for the taut band, which may include a tender nodule. active loci in the tender nodule of a taut band. 2. Exquisite spot tenderness of a nodule in a taut band: DIAGNOSTIC VALUE OF A Palpating through a taut band, the clinician should identify the tender nodular area. Digital compression REFERRED PAIN PATTERN of the nodule may elicit a referred pain pattern (RPP). Identification of the RPP is an important and helpful confirmatory criterion to the diagnosis of a myofascial 3. Patient pain recognition: Digital ischemic compres­ trigger point syndrome. In Travell and Simons' writings sion on the tender nodule may reproduce the patient's from the early 1 980s,15 great significance was placed on pain symptom. Patients will usually identify that as the RPP: \"The patient's pattern of referred pain is usually \"their usual pain.\" Patient pain recognition does not the key to the diagnosis of a myofascial pain syndrome.\" In necessarily have to extend throughout the entire a recent aIgometry study16 eI'lCl.tl.ng pressure over normaI RPP, which is characteristic for the specific muscle. muscle tissue in subjects with myofascial trigger points, Eliciting the patient's pain recognition is a strong referred pain was elicited in 68% of patients with active essential criterion and will discriminate an active trigger points and in 23.4% of patients with latent trigger trigger point from a latent one. points. In the same study, direct pressure over the trigger point elicited an RPP in all subjects with active myofas­ 4. Painful range of motion at the end of range: It is a ciaI trigger points but only in 46.8% of muscles with common characteristic of myofascial trigger points to latent ones. When pressure was applied over any point of restrict range of motion and produce pain at the end the taut band, an RPP was elicited again in all subjects of the range. A painful muscle at the end of the range with active myofascial trigger points but only in 36.2% of movement should not be confused with the RPP or with latent ones. Hong and Simons17 concur that with the positive stretch sign (PSS). \"referred pain is not a specific sign of a myofascial trigger point (MTrP), but it certainly occurs more often (and is CONFIRMATORY CRITERIA much easier to elicit) in an active MTrP region than in a latent one or a normal muscle tissue.\" 1. Local twitch response (LTR): Eliciting a LTR may take place through snapping palpation across the taut As previously stated, it :s the belief of the authors of band, especially across the fibers of the trigger point's this book that making a decision on what muscle to treat active locus. LTR may be identified visually or by looking only at the RPP may lead to a poor judgment. through palpation. Often, patients present themselves with variable RPPs that belong to more than one muscle. At the same time, 2. Local twitch response via needle penetration: Eliciting an LTR may take place through needle pen-

Myofascial Diagnosis 47 the RPP elicited by an active myofascial trigger point can REVIEW QUESTIONS be very different than the patient pain recognition. This complicates a diagnosis even further. Instead by placing I. Digital ischemic compression on the tender nod­ primary importance on the essential trigger point criteria ule may reproduce the patient's pain symptom. described above, with our assessment using the biome­ T his is called _________ chanics of the injury we can arrive at the correct myofas­ cial diagnosis with great precision. 2. A patient's pain recognition is one of the confir­ MVOFASCIAL DIAGNOSIS matory criteria for the identification of a myofas­ The following steps can be followed in myofascial diag­ cial trigger point. nosIs: 1 . Take a history. Look for sudden onset from acute True False injury, trauma, overload stress; or gradual onset with 3. A referred pain pattern is one of the essential cri­ chronic overload, microinjury, microtrauma, repeti­ tive trauma. Objectively identify the patient's life teria for the identification of a myofascial trigger problems from their point of view and understand their jobs, personal relationships, and other stressors point. of daily life. IS 2. E tablish biomechanics of injury from the history and True False questions-and-answers. 3. Palpate for a taut band: If the muscle is accessible 4. Eliciting a patient's pain recognition is a very ;palpate for the taut band, which may include a tende important criterion and will discriminate a nodule. trigger point from a one. 4. Identify tender nodules, usually within the taut band. 5. Identify patient pain recognition: Patient pain recog­ 5. Pain in the muscle at the end of the range of the nition does not necessarily have to extend through­ movement is defined as positive stretch sign. out the entire RPP. The patient may identify the patient pain recognition sign in only a portion of the True False expected RPP. Differential diagnosis between an active trigger point and a latent one can be achieved 6. Painful end range of motion is one of the essential with the presence of patient pain recognition. 6. Painful range of motion at the end of range. Pain at criteria for the identification of a myofascial trigger the attachments and/or the muscle belly may be pres­ ent during end range of motion. point. 7. Identify possible local twitch response. Eliciting a LTR may take place through snapping palpation True False across the taut band. In cases of very high trigger point activity, mere compression of the trigger point 7. Presence of spontaneous EMG activity when an may elicit an LTR. 8. Establish referred pain pattern: An RPP characteristic EMG needle slowly approaches the area of active for the specific muscle may be elicited during digital compression on the area of the active locus. The RPP loci in the tender nodule of a taut band is one of may be different from the patient pain recognition. 9. Identify possible weakness of the involved muscle. At the confirmatory criteria for the identification of a times, application of manual muscle testing will demonstrate weakness of the myofascially involved myofascial trigger point. muscle. 1 0. Correlate with other orthopedic/neurologic tests, True False including special tests and differential diagnostic tests. 1 1. Establish a diagnosis in myofascial terms.

48 Chapter 9 REFERENCES 9. Gerwin RD. Myofascial pain syndromes in the upper extremity.} Hand Ther. 1997; J 0:130-6. I. Fischer AA. Reliability of the pressure algometer as a meas­ ure of myofascial trigger point sensitivity. Pain. 10. Simons DG. Examining for myofascial trigger points. Arch 1987;28:411-4. Phys Med Rehabil. 1993;74:676-7. 2. Gerwin R, Shannon S. lnterexaminer reliability and 11. Simons DO. The nature of myofascial trigger points. CUn} Illyofascial trigger points. Arch Phys Med Rehabil. Pain. 1995;11:83-4. 2000;81:1257-8. 12. Simons DG. Undiagnosed pain complaints: trigger pointsl 3. Gerwin RD, Shannon S, Hong CZ, Hubbard 0, Gevirtz R. Clin} Pain. 1997;13:82-3. Interrater reliability in myofascial trigger point examina­ tion. Pain. 1997;69:65-73. 13. Travell ]G, Simons DG, Simons LS. Myofascial Pain and Dysfunction: The Trigger Point Manual-U/JIJer Half of Body. 4. Hsieh CY, I-long CZ, Adams AH, et at. Interexaminer reli­ Baltimore, Md: Williams & Wilkins; 1999. ability of the palpation of trigger points in the trunk and lower limb Illuscles. Arch Phys Med Rehabil. 2000;81:258- 14. Wolfe F, Simons DG, F ricton J, et al. The fibromyalgia and 64. myofascial pain syndromes: a preliminary study of tender points and trigger points in persons with fibromyalgia, 5. Nice DA, Riddle DL, Lamb RL, Mayhew TP, Rucker K. myofascial pain syndrome and no disease. } Rheumatol. lntertester reliability of judgments of the presence of trigger 1992;19:944-51. points in patients with low back pain. Arch Phys Med Rehabil. 1992;73:893-8. 15. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol l. Baltimore, Mel: Williams & 6. Njno KH, Van der Does E. T he occurrence and inter-rater Wilkins; 1983. reliability of myofascial trigger points in the quadratus lum­ borum and gluteus medius: a prospective study in non-spe­ 16. Hong CZ, Chen YN, Twehous 0, Hong D. Pressure thresh­ cific low back pain patients and controls in general prac­ old for referred pain by compression on the trigger point tice. Pain. 1994;58:317-23. and adjacent areas.} Musculoskel Pain. 1996;61-79. 7. Tunks E, McCain GA, Hart LE, et at. The reliability of 17. Hong CZ, Simons DG. Pathophysiologic and electrophysi­ examination for tenderness in patients with myofascial ologic mechanisms of myofascial trigger points. Arch Phys pain, chronic fibromyalgia and controls. } Rheumatol. Med Rehabil. 1998;79:863-72. 1995;22:944-52. 18. Travell]. Advances in Pain Research and Therapy: Chronic 8. Gerwin RD. Neurobiology of the myofascial trigger point. Myofascial Pain Syndromes Mysteries of the History. New Bail/ieres Clin Rheumatol. 1994;8:747-62. York: Raven Press Ltd; 1990;17:129-137.

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Chapter 10 fter myofascial diagnosis has been established, the The authors of this book utilize an alternating (not continuous) current and increase the intensi­ Afollowing treatment sequence can be applied. ty to the point in which quick but gentle muscular 1. Modalities to the affected muscle. The application of contractions are produced. The application of this heat and other modalities (hot packs, cold packs, kind of electrical stimulation may have a similar ultrasound, etc) to the involved muscle will help effect as eliciting an LTR during dry needling. At increase blood circulation in the area and promote the same time, the muscle seems to fatigue and a relaxation. Duration and method of application further degree of relaxation is achieved. Electrical varies depending on the modality selected. The clini­ stimulation may also be applied with the use of a cian must consider all applicable contraindications probe over the trigger point. before the application of any modality. Some of the ';:' Low-level laser therapy (LLLT ) applied over the possible modalities are: area of a trigger point with three IS-second appli­ ';:- Hot packs to promote a general increase in blood cations has been found to be very effective in nor­ circulation and a feeling of relaxation. Apply for malizing skin resistance, which is an indication of 15 to 20 minutes over the involved muscle. myofascial trigger point normalization. I LLLT is -:;: Ultrasound as a heating modality will transmit usually applied with helium-neon 632.8 nm vibrational energy up to approximately 5 cm, gen­ (nanometers) visible red or infrared 820 to 830 nm erating heat within the tissue. The exact mecha­ continuous wave and 904 nm pulsed emission.2 nism on how ultrasound may benefit in the treat­ Recent studiesl-3 indicate a decrease in muscle ment of myofascial trigger points must be further rigidity, increase of mobility, and a decrease in researched. Pulsed ultrasound may be used over a pain4-6 in muscles with myofascial trigger points. myofascial trigger point. Application of continu­ LLLT improves local microcirculation, increases ous ultrasound will require continuous movement oxygen supply to hypoxic cells in the trigger point of the sonic head during its application. There are areas, and at the same time can help remove col­ no studies available to indicate the effectiveness of lected waste products. According to Tam,6 the one method versus the other on myofascial trigger semiconductor or laser diode (GaAs, 904 nm ) is points. the most appropriate choice in pain reduction ';: Phonophoresis and iontophoresis to deliver drugs, therapy. A low-power density laser acts on the such as hydrocortisone, lidocaine, and others. The prostaglandin (PG) synthesis, increasing the low level of penetration, up to 1 cm under the change of PGG2 and PGH2 into PGI2 (also skin, makes it difficult for the drug to reach the called prostacyclin or epoprostenol). The latter is submuscular tissue. the main product of the arachidonic acid into the ,;: Electrical stimulation in various forms has been endothelial cells and into the smooth muscular used in the treatment of myofascial trigger points. cells of vessel walls, which have a vasodilating and

52 Chapter 10 Figure 10-1. Flat palpation of myofascial trig­ Figure I 0-2. Pincer palpation of myofascial ger points using the thumb or fingers (reprint­ trigger points (reprinted with permission from ed with permission from Travell JG, Simons DG, Travell JG, Simons DG, Simons LS. Myofascial Simons LS. Myofascial Pain and Dysfunction The Pain and Dysfunction The Trigger Point Manual­ Trigger Point Manual-Upper Half of Body. Upper Half of Body. Baltimore, Md:Williams & Baltimore, Md:Wiliiams & Wilkins; 1999). Wilkins; 1999). anti-inflammatory action. Simunovic3.7 reports toward the center. Once new tissue resistance that pain diminished in 70% of individuals with appears, the clinician should stop and wait with acute pain and in 60% of individuals with chronic steady force against the tissue, then repeat this pain after the application of LLLT. (An important cycle several times. At the end, either further point must be noted: no modality may replace the relaxation of the tissue will be felt or no new gains manual therapeutic intervention provided by the will be achieved. The muscle should be placed in clinician. ) a relaxed position but not a very shortened one. 2. Trigger point therapy can be applied in various forms. Pressure application varies in quantity and may These include: start from a few ounces up to a couple of pounds. -:\" Progressive pressure technique: This manual ther­ The clinician should always be guided by the apy technique requires the use of hands or fingers patient's pain tolerance, and constant feedback and can be applied in the form of flat palpation should be provided by the patient. (Figure 10-1) or pincer palpation (Figure 10-2). The clinician may use the thumbs or the fingers, Several other techniques set a time limitation to the knuckles, the elbows, or a combination of all the application of the digital compression. The to apply pressure. Rather than applying a fast authors do not believe that such a limitation is ischemic compression on the tissue that will create necessary, provided that the clinician treats with­ excessive pain and muscle guarding, we utilize a in reason. We usually apply this progressive pres­ more gentle technique called progressive pressure sure technique for at least 30 seconds to up to 2 technique. The technique is performed as follows: minutes at a time. The treatment will finally Use the thumbs or four fingers of one or both release the contractured sarcomeres of the con­ hands and apply steady pressure, moving inward traction knots in the myofascial trigger point toward the center. Once tissue resistance is felt, area.B•11 Travel! calls a similar technique \"ischemic stop and wait until resistance dissipates. At this compression\" because upon release, the skin is at point, the clinician may feel a slow release or a first blanched and then shows reactive hyper­ \"melting away\" sensation of the tissue under the emia.II,12 The patient should breathe deeply and treating fingers. The clinician should then proceed slowly while the clinician progressively increases with further steady pressure, moving again inward the pressure. Deep relaxation is very important for effectiveness of the technique.

Myofascial Treatment 53 Some clinicians may use different types of trigger ultimately leads to a longer muscle fiber with more point treatment devices that allow them to apply sarcomeres in series.24 The stretching technique the trigger point techniques without discomfort to appropriate for myofascially involved muscles must their fingers and hands. take into account the pathologic overshortening of '\" Postisometric relaxation, reciprocal inhibition, the involved muscle fibers. To make a clear distinc­ contract-relax technique, muscle energy tech­ tion about the specific way this stretching should be nique, strain-counterstrain technique, massage performed, we call it myofascial stretching. When there and myofascial release techniques may all affect is an active trigger point in a muscle, only a portion myofascial trigger points in various ways. This of specific muscle fibers is involved. If someone per­ text, however, emphasizes the progressive pressure forms a general, relatively fast stretch in this muscle, technique as the treatment of choice. all healthy, noninvolved fibers will stretch, At the 'i' Trigger point dry needling is a very effective same time, the sarcomeres above and below the trig­ approach that uses a fine flexible needle (usually ger point locus will overstretch to accommodate the an acupuncture needle ) to elicit LTRs from the change in muscle length, while the shortened trigger trigger point and finally inactivate it. point area will develop an increase in tension during 'i' Trigger point injections using a nonmyotoxic local this fast stretch, On the contrary, myofascial stretch is anesthetic can be useful. lidocaine 0.5%l3 or a very specific in isolating the muscle and very slow in procaine injectionll•IZ,14 has been recommended rate to actually affect these myofascially involved by various researchers; however, eliciting an LTR fibers. during the procedure is of utmost importance.13 Since the origin of myofascial trigger points lies on Proper myofascial stretching requires deep relax­ the premise of dysfunctional endplates, sensible ation with proper concentration and breathing. This use of botulinum toxin A has been found to be will inhibit the \"gamma spindle\" response. The effective in inactivating trigger points.15-19 gamma spindle system is a servo-mechanism (biofeed­ 3. For effective trigger point therapy, it must always be back system) within a muscle that causes the muscle followed by myofascial stretching (MFS) exercises. to shorten when rapidly stretched.24 The response of Travell and Simons state \"the key to treating trigger the gamma spindle is rate dependent (ie, only rapid points is to lengthen the muscle fibers that are short­ lengthening causes the muscle to contract, whereas a ened by the trigger point mechanism.\"ID To efficient­ slow rate of deformation will not elicit a response ) . ly deliver power to a movement, a muscle is placed in The muscle must b e allowed t o \"relax out\" rather a gentle stretch before performing a shortening con­ than \"push through,\" This is a subtle difference that traction. Before an activity is performed, a muscle requires concentration on what is occurring in the must be able to properly stretch and lengthen without patient's body, causing injury to other structures in the muscu­ loskeletal system. An injured muscle loses this prop­ MFS is different than regular stretching in the sense erty. Therefore, after the clinician helps the muscle that it is very specific for the muscle under treatment relax by inactivating the trigger point via progressive and requires a narrow therapeutic range,25 pressure technique, he or she must stretch the muscle Overstretching during the application of MFS should to maintain the degree of relaxation and bring the be avoided and absolute relaxation must be achieved. muscle to an ergonomically correct state. In other words, inactivation of the myofascial trigger points IngberZ5 suggests the following sequence for the should be followed by lengthening the overshortened application of MFS: sarcomeres. An increase in the range of motion immediately following passive stretch has been iden­ 'i' Place the muscle to be stretched at the position tified in the literature and can be explained by the where tension is sensed in the target muscle, at viscoelastic behavior of muscle and short-term the end range of motion. changes in muscle extensibility.ZD,21 Passive stretch that exceeds 30 seconds can be sufficient to obtain 'i' While exhaling, allow the muscle to relax so that increased mobility.22 it stretches to an increased length. De Deyne, in a recent study,23 identified that ·:i:· Hold the newly gained position while inhaling. mobility gained through rehabilitation-type stretch­ '\" Gain further length with each succeeding exhal­ ing produces a permanent adaptive response since the mobility is maintained, Apparently, through the ation for 20 to 45 seconds, moving at the rate of process of myofibrilogenesis, a stretched muscle fiber 3 to 4 mm/sec, allowing the muscle to \"relax out\" ,, rather than \"push through, Z5 To ensure the MFS is performed correctly, the clini­ cian must be very clear and thorough when instruct­ ing the patient. Caution: During the application of MFS, eliciting a positive stretch sign (PSS) is an indication that the

54 Chapter 10 clinician or patient is pushing through the stretch Figure 10-3. Application of the spray and stretch tech­ more than necessary. In that case, the clinician nique enables the clinician to achieve an increased muscle should either decrease the amount of MFS or return length, avoiding local muscle discomfort and muscle the muscle to a relaxed position and perform addi­ guarding (video screen capture). tional trigger point therapy before additional MFS is performed. MFS will be given to the patient as a ;;, Low-resistance isotonic strengthening exercises home exercise program and should be repeated four to ;;, Moderate resistance isotonic strengthening six times daily with two repetitions each time. ;;:. Isokinetic strengthening, starting with concentric­ Vapocoolant spray may be used in a spray and stretch concentric and progressing to concentric-eccen­ technique to inactivate acute myofascial trigger tric contractions points.II,26 Ethyl chloride27,z8 or fluorimethanelO,Z9 ;;, Maximum resistance isotonic exercise can be effectively used. There are, however, environ­ ;;:. Throughout this strengthening program, safe mental concerns regarding both products and an closed kinetic chain exercises should be performed informed decision about their use must be made. The both as clinic training and as a home exercise pro­ clinician should carefully read the manufacturer's gram product information and guidelines. The recom­ 6. Proprioceptive training. Microtrauma and myofascial mended treatment method when using vapocoolant trigger points in a muscle create uncoordinated mus­ spray follows (Figure 10-3): cle function.H·37 Contraction rate in the muscle ;;, Have the patient sit in a relaxed position and posi­ increases and, therefore, the time it takes for a muscle to recruit the maximum number of motor units tion the muscle until slight tension is felt. required for a specific contraction slows clown. To pre­ :;, Hold the spray bottle 8 to 12 inches above the skin vent injury-especially microinjury-fast reflex mus­ cle contraction is required to protect the involved and spray three sweeps from above the trigger J. o.mts.35,36'38 0urm. g propn.oceptl.ve tram. m. g, a cI'[nt. - point area but into the RPP zone, continue cian or an instrument introduces unexpected external through the trigger point area, then below the forces of random frequency, magnitude, and direction trigger point area but into the RPP zone. to different parts of the patient's body, facilitating var­ ;;, After three sweeps have been applied, gently ious receptors. The goal is to increase proprioceptive stroke the skin with your palm into the same direc­ flow and facilitate the proprioceptive system, espe­ tion as the spraying. cially those pathways responsible for equilibrium, pos­ ;;, Apply gentle stretch, allowing the muscle to elon­ ture, and muscle control.36 Various devices, such as gate. trampolines, balance and rocker boards, balance ;;:. Repeat the same cycle up to three consecutive shoes, and others have been used to facilitate the times, always being aware that if a PSS develops, receptors (Figures 10-4 and 10-5). the technique must immediately stop. Always 7. Home exercise program. Patients must be instructed remember that pain or tension felt directly from in self-stretching exercises to be performed between the muscle that has been stretched does not qual­ treatments. It is very important that patients under­ ify as a PSS. stand how to correctly perform a MFS. The patient 4. Post-treatment modalities. If the skin is sore or if post-injection soreness persists, apply cold packs to decrease sensitivity in the area. 5. Muscle strengthening exercise sequence. Muscle strengthening exercises are important and should be applied as part of the myofascial treatment. Usually, the clinician will notice an increase in muscle strength right after the application of MFS.Z5.30,31 However, a systematic muscle strengthening program should be applied as part of the treatment. The authors of this book initiate muscle strengthening exercises after the patient has achieved 70% com­ bined range of motion of the involved muscle and joint.n,B The following sequence of muscle strength­ ening exercises is recommended: .:;, Isometric strengthening in various ranges of motion

Myofascial Treatment 55 Figure 10-4. Application of proprioceptive training tech­ Figure 10-5. Application of proprioceptive training tech­ niques (video screen capture). niques (video screen capture). can apply the MFS four to six times daily. Recent S. Myofascial stretch is very specific in isolating the research26 demonstrated that a home exercise pro­ gram that consisted of ischemic pressure and sus­ muscle and very slow in rate to actually affect the tained stretching was found to be effective in reduc­ ing sensitivity of myofascial trigger points and myofascially involved fibers. decreasing pain intensity in individuals with neck anJ upper back pain. When the clinician introduces True False the muscle strengthening exercise sequence or propri­ oceptive training, appropriate home exercises should 6. During the myofascial stretch, the clinician hopes be given to the patient. to activate the muscle spindle. True False REVIEW QUESTIONS 7. Myofascial stretching is different than regular stretching in that it is very specific for the muscle I. Heating modalities may help to increase blood cir­ under treatment and requires a narrow therapeu­ culation at the trigger point area and promote tic range. overall relaxation. True False True False 8. T he goal of proprioceptive training is to increase 2. According to the progressive pressure technique, proprioceptive flow and facilitate the propriocep­ I S to 20 pounds of force must be applied on the tive system, especially those pathways responsible trigger point. for equilibrium, posture, and muscle control. True False True False 3. Application of the trigger point therapy should 9. A 2S-year-old dancer presents with left heel pain. After careful evaluation and biomechanical analy­ take place with the muscle in its maximum short­ sis, it becomes obvious that the patient has active myofascial trigger points in the left tibialis posteri­ ened position. or muscle. What is likely the most proper inter­ vention? True False A. Treat with modalities and apply trigger point therapy and myofascial stretching exercises to 4. Application of the trigger point therapy should the left tibialis posterior. Provide a regular home exercise program. take place with the muscle in its maximum length­ B. Treat with modalities and apply myofascial stretching exercises to the left tibialis posterior. ened position. True False

56 Chapter 10 No need for trigger point therapy because the REFERENCES patient is very active as a dancer and the trigger point will resolve by itself. Provide a regular 1. Snyder-Mackler L, Bork C, Bourbon B, Trumbore O. Effect home exercise program. of helium-neon laser on musculoskeletal trigger points. C. Treat with modalities and apply trigger point Phys Ther. 1986;66:1087-90. therapy to the left tibialis posterior. No need for myofascial stretching exercises because the 2. Simunovic Z. Low level laser therapy with trigger points patient stretches frequently as a dancer. Provide technique: a clinical study on 243 patients. 1 Clin Laser Med a regular home exercise program. Surg.1996;14:163-7. D. Treat with modalities and apply trigger point therapy and myofascial stretching exercises to 3. Simunovic Z, Trobonjaca T, Trobonjaca Z. Treatment of the left tibialis posterior. medial and lateral epicondylitis-tennis and golfer's elbow-with low level laser therapy: a multicenter double 10. A patient has an immobilized shoulder due to an blind, placebo-controlled clinical study on 324 patients. 1 open rotator cuff repair. He has active trigger Clin Laser Med Surg. 1998;16:145-5 !. points in the subscapularis muscle and abduction is limited to 85 degrees. According to the authors' 4. Ceccherelli F, Altafini L, Lo Castro G, Avila A, Ambrosio philosophy and method of treatment, what is like­ F, Giron GP. Diode laser in cervical myofascial pain: a dou­ ly the most appropriate intervention? ble-blind study versus placebo. Clin} Pain. 1989;5:301-4. A. Patient should receive modalities, trigger point therapy, and myofascial stretching exercises for 5. Sieron A, Adamek M, Cieslar G, Zmudzinski J. Personal the subscapularis muscle and isokinetic experience in clinical use of low power laser therapy. Przegl strengthening for the subscapularis. Lek. 1995;52:13-5. B. The patient should receive modalities, trigger point therapy, and myofascial stretching exercis­ 6. Tam G. Low power laser therapy and analgesic action. 1 es for the subscapularis muscle. A muscle Clin Laser Med Surg. 1999; 17:29-33. strengthening exercise program for the sub­ scapularis should be initiated as soon as the 7. Simunovic Z. Low level laser therapy with trigger points patient reaches 100 degrees of abduction. technique: a clinical study on 243 patients. 1 Clin Laser Med Gentle muscle strengthening that addresses Surg.1996;14:163-7. other muscles can be immediately initiated. C. The patient should receive modalities, trigger 8. Simons OG. Myofascial pain syndromes. Arch Phys Med point therapy, and myofascial stretching exercis­ Rehabil. 1984;65:561. es for the subscapularis muscle. A muscle strengthening exercise program for the sub­ 9. Travell JG, Simons DG. Myofascial Pain and Dysfunction: scapularis should be initiated as soon as the The Trigger Point Manual-The Lower Extremities. Media, patient reaches 125 degrees of abduction. Pa: Williams & Wilkins; 1983. Gentle muscle strengthening that addresses other muscles can be immediately initiated. 10. Travell JG, Simons OG, Simons LS. Myofascial Pain and D. The patient should receive modalities, trigger Dysfunction: The Trigger Point Manual-U/)per Half of Body. point therapy, and myofascial stretching exercis­ Baltimore, Md: Williams & Wilkins; 1999. es for the subscapularis muscle. A muscle strengthening exercise program for the sub­ 11. Travell JG, Simons OG. Myofascial Pain and Dysfunction: scapularis should be initiated as soon as the The Trigger Point Manual. Vol I. Baltimore, Md: Williams & patient reaches 155 degrees of abduction . Wilkins; 1983. Gentle muscle strengthening that addresses other muscles can be immediately initiated. 12. Simons OG, Travell JG. Myofascial origins of low back pain. !. Principles of diagnosis and treatment. Postgrad Med. 1983;73:66,68-70,73 passim. 13. Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point. T he importance of the local twitch response. Am} Phys Med Rehabil. 1994;73:256-63. 14. Travell JG, Rinzler S, Herman M. Pain and disability of the shoulder and arm: treatment by intramuscular infiltration with procaine hydrochloride. lAMA. 1942; 120:417-422. 15. Acquadro MA, Borodic GE. Treatment of myofascial pain with botulinum A toxin. Anesthesiology. 1994;80:705-6. 16. Cheshire WP, Abashian SW, Mann JO. Botulinum toxin in the treatment of myofascial pain syndrome. Pain. 1994;59:65-9. 17. Oiaz JH, Gould HJ Ill. Management of post-thoracotomy pseudoangina and myofascial pain with botulinum toxin. Anesthesiology. 1999;91:877-9.

Myofascial Treatment 57 18. Gerwin RD. Neurobiology of the myofascial trigger point. and E. Van der Does, Pain, 58 (1994) 317-323. Pain. BailLieres Clin Rheumatol. 1994;8:747-62. 1995;61:159. 19. Porta M. A comparative trial of botulinum toxin type A 29. Simons DG, Travell JG, Simons LS. Protecting the ozone and methylprednisolone for the treatment of myofascial layer. Arch Phys Med Rehabil. 1990;71:64. pain syndrome and pain from chronic muscle spasm. Pain. 2000;85:101-5. 30. lngber RS. Shoulder impingement in tennis/racquetball players treated with subscapularis myofascial treatments. 20. Best TM. Soft-tissue injuries and muscle tears. Clin Sports Arch Phys Med Rehabil. 2000;81:679-82. Med. 1997; 16:419-34. 31. Wilson GJ, Elliott Be, Wood GA. Stretch shorten cycle 21. Best TM, McElhaney J, Garrett WE, Myers BS. performance enhancement through flexibility training. Characterization of the passive responses of live skeletal Med Sci Sports Exerc. 1992;24:116-23. muscle using the quasi-linear theory of viscoelasticity. ] Biomech. 1994;27:413-9. 32. Kostopoulos D, Rizopoulos K. Trigger point and myofascial therapy. Advance for Physical Therapists. 1998:25-28. 22. Bandy WD, Irion JM. The effect of time on static stretch on the flexibility of the hamstring muscles. Phys Ther. 33. Kostopoulos D, Rizopoulos K, Brown A. Shin splint pain: 1994;74:845-52. the runner's nemesis. Advance for Physical Therapists. 1999:33-34. 23. De Deyne PG. Application of passive stretch and its impli­ cations for muscle fibers. Phys Ther.2001;81:819-827. 34. Freeman M, Dean M, Hanham 1. T he etiology and preven­ tion of functional instability of the foot. ] Bone Joint Surg 24. Kandel E, Schartz J, Jessell TM. Principles of Neural Science. Br. 1965;678. 4th cd. New York: McGraw-Hili; 2000. 35. Janda v. Muscle strength in relation to muscle length, pain 25. Ingber R. Myofascial Pain in Lumbar Dysfunction. and muscle imbalance. International Perspectives in Physical Phihdelphia, Pa: Hanley & Belfus Inc; 1999. Theraj)y. New York: Churchill Livingstone; 1993;8:83-91. 26. Hanten WP, Olson SL, Butts NL, Nowicki AL. 36. Janda V, Va'Vrota M. Sensory motor stimulation. In: Effectiveness of a home program of ischemic pressure fol­ Liebenson C. Rehabilitation of the Spine. Baltimore, Md: lowed by sustained stretch for treatment of myofascial trig­ Williams & Wilkins; 1996:319-328. ger points. Phys T her. 2000;80:997-1003. 37. Kurtz A. Chronic sprained ankle. Am] Surg. 1939;158. 27. Gunn C. The Gunn A/)/)roach to the Treatment of Chronic Pain-Intramuscular Stimulation for Myofascial Pain of 38. Twomey L, Janda v. Physical Therapy of the Low Back: Radiculo/)athic Origin. London: Churchill Livingstone; Muscles and Motor Control in Low Back Pain: Assessment and 1996. Management. New York: Churchill Livingstone; 253-278; 2000. 28. Marcus N, Kraus H, Rachlin E. Comments on KH Njoo

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Chapter I I t is a very common phenomenon when treating tralateral gluteus maximus, which has a direct con­ nection to the thoracolumbar fascia, the furthest part I patients with a chronic or unresolved myofascial trig­ of the fascia of the latissimus dorsi. Abnormal stress­ ger point syndrome to see that other exogenous factors es, tension, and overload may create myofascial trig­ may have a negative effect on the condition. Usually, ger points in any of the muscles mentioned here. It these patients do well immediately following the treat­ becomes obvious how important it is to thoroughly ment, but a couple of days later they regress to the initial evaluate the patient. Only then can the clinician state. The reason for that regression is an uncontrolled­ manage to identify such perpetuating factors and cor­ and possibly unknown to the patient and to the clini­ rect them. cian-factor that perpetuates the dysfunction. These are * A classic example of an iatrogenic perpetuating factor called perpetuating factors and can be related to abnormal is to provide the patient with a cane of improper body positions, po tural positions, skeletal asymmetries, as length. Continuous use of a cane that is either too tall well as activities that increase mechanical stresses causing or too short will cause asymmetries and will apply reactivation of myofascial trigger points. abnormal stresses to the muscles of the upper body. Nutritional factors may play a role in the perpetuation Examples of such conditions include: of a myofascial trigger point syndrome. It is recommended * An asymmetry such as a leg length discrepancy that that patients with a chronic myofascial trigger point syn­ drome take vitamins BI, B6, BIz, folic acid, and vitamin C. exceeds 0.5 to 1 cm. Such a discrepancy will cause Metabolic and endocrine inadequacies, as well as psy­ muscular asymmetries that will extend from the lower chological and behavioral issues, may act as perpetuating extremity to the sacroiliac joint, the pelvis, and fur­ factors in a myofascial trigger point syndrome. The clini­ ther to the spine, producing abnormal stresses. cian should be able to identify such factors and make * Muscle imbalances can become stressors that will appropriate referrals if the issue is outside the scope of his activate myofascial trigger points. For example, tight­ or her practice. ness on the right biceps femoris (long head) will pro­ duce abnormal tension on the ipsilateral sacrotuberus ligament. This is connected to the fascia of the con-

60 Chapter I I 4. A patient presents with pain in the right sacroiliac and gluteal region. Myofascial evaluation reveals REVIEW QUESTIONS presence of an active myofascial trigger point on the gluteus medius muscle. Further evaluation I. Perpetuating factors are factors that are uncon­ reveals a Morton's foot condition (second metatarsal longer and lower than the first, causing trolled and possibly unknown to the clinician and foot pronation, tibial rotation, femoral adduction, and internal rotation during ambulation). What is patient that prolong a patient's myofascial dysfunc­ the recommended treatment plan? A. Treat the gluteus medius muscle myofascially tion. and stretch the heel to correct the foot condi­ tion. True False B. Consider Morton's foot as a perpetuating fac­ tor. Resolve Morton's foot with the proper 2. Perpetuating factors can be related to abnormal orthotic device and treat the gluteus medius muscle myofascially. body positions, postural positions, and skeletal C. Consider Morton's foot as a perpetuating fac­ tor. Resolve Morton's foot with the proper asymmetries, as well as activities that increase orthotic device. No treatment is necessary for the gluteus medius because the muscle has an mechanical stresses causing reactivation of active trigger point and will resolve by itself. D. Treat the gluteus medius muscle myofascially myofascial trigger points. and stretch the second metatarsal to correct the foot condition. True False 3. Nutritional factors play no role in the perpetua­ tion of a myofascial trigger point syndrome. True False

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Chapter 12 Trigger point dry needling technique involves inser­ dry needling produced a higher incidence of local post­ tion and repetitive manipulation of a fine and flex­ treatment soreness. Hong and others, however, empha­ ible needle in the trigger point of a muscle to pro­ sized the importance of eliciting a local twitch response duce a local twitch response, resulting in muscle relax­ (LTR) during the application of any needling tech­ ation. nique.2,11.14 Travel! and Simons, I in Myofascial Pain and The mechanism of dry needling action that seems to Dysfunction: The Trigger Point Manual, state that there are provide muscle relaxation and pain relief, according to several ways to treat trigger points, including spray and Fischer, is that dry needling mechanically breaks up the stretch, ischemic compression, injection with saline or nodularity of the tissue.IS.17 Gunn supports that there is a local anesthetic, and dry needling. Dry needling requires histamine release that causes local irritation and relax­ the greatest precision and the most repetition. There are ation of the muscle. IS In Ingber's opinion, the mechanism several studies providing evidence that dry needling is of action is one of a decrease in the stiffness of the muscle more effective than other techniques, including local we are treating through an electrical event.19 Decrease of anesthetics.z, 3 stiffness increases the flexibility of the muscle that is main­ tained through the myofascial stretching exercises.zo.n In 1979, Lewit,4,5 in his study published in Pain, demonstrated the effectiveness of dry needling. Frost et The advantage of dry needling techniques over other a16.10 demonstrated that injection of normal saline into techniques is that we can establish a painless full range of the trigger point was more effective than injecting a local motion at the time of treatment (immediate response). It anesthetic. They proposed that it was not the injectable also improves a kinesthetic sense, because we can imme­ material that they used, but the needling procedure itself diately teach the patient full painless range of motion, that produced such results. Inserting the needle at the site which is the ultimate aim of myofascial treatment. Other caused a stimulation of the reflex arc. Because the afferent advantages of dry needling include absence of allergic pathway was the muscle, the muscle relaxed.6,s Therefore, reactions, decreased chance of hematomas, and treatment relaxation of the muscle was obtained through the spinal of deep muscles close to neurovascular bundles. The dis­ reflex arc. advantage is that the technique is painful and may pro­ duce post-treatment soreness. In a clinical trial of 58 patients with myofascial trigger points on the upper trapezius muscle, application of trig­ Trigger point dry needling is an invasive procedure and ger point dry needling technique was found to be equally should be applied only by those clinicians whose state effective as injection with 0.5% lidocaine in reducing licenses permit such practice. Dry needling must not be pain intensity, muscle pressure sensitivity on pressure confused with acupuncture. algometry, and cervical range of motion.2 Trigger point

64 Chapter 12 REVIEW QUESTIONS points: a comparison. Arch Phys Med Rehabil. 1997;78:957- 60. I. Trigger point dry needling technique involves 4. Lewit K. The needle effect in the relief of myofascial pain. insertion and repetitive manipulation of a fine and Pain. 1979;6:83-90. flexible needle into the trigger point area of a mus­ 5. Lewit K. Manipulative Therapy in Rehabilitation of the Locomotor System. Oxford, England: Butterworth­ cle. Heinemann; 1999. True False 6. Frost A. Diclofenac versus lidocaine as injection therapy in myofascial pain. Scand} Rheumatol. 1986;15:153-6. 2. A local twitch response during a dry needling ses­ 7. Frost A. Diclofenac compared with lidocaine in the treat­ sion is an unwanted event and results in harming ment of myofascial pain by injections. Ugeskr Laeger. 1986;148:1077-8. the muscle. 8. Frost FA, Jessen B, Siggaard-Andersen J. A controlled dou­ True False ble-blind comparison of mepivacaine injection versus saline injection for myofascial pain. Lancet. 1980;1:499- 3. T he mechanism of dry needling action that seems 500. to provide muscle relaxation and pain relief, 9. Frost FA, Jessen B, Siggaard-Andersen J. Myofascial pain treated with injections. A controlled double-blind trial. according to Fischer, is that dry needling mechani­ Ugeskr Laeger. 1980;142:1754-7. cally breaks up the nodularity of the tissue. 10. Frost FA, Toft B, Aaboe T. Isotonic saline and methylpred­ nisolone acetate in blockade treatment of myofascial pain. True False A clinical controlled study. Ugeskr Laeger. 1984;146:652-4. 4. Ingber supports that there is a histamine release 11. Hong CZ, Hsueh TC. Difference in pain relief after trigger point injections in myofascial pain patients with and with­ that causes local irritation and relaxation of the out fibromyalgia. Arch Phys Med Rehabil. 1996;77:1161-6. muscle. 12. Hong CZ, Simons DG. Pathophysiologic and electrophysi­ ologic mechanisms of myofascial trigger points. Arch Phys True False Med Rehabil. 1998;79:863-n. 5. A disadvantage of dry needling is that it is painful 13. Simons DG. The nature of myofascial trigger points. Clin} Pain. 1995;11:83-4. and may produce post-treatment soreness. 14. Simons D, Hong C, Simons LS. Nature of myofascial trig­ True False ger points, active loci. Journal of Musculoskeletal Pain. 1995;3(lSuppl):62. 6. Trigger point dry needling is an invasive procedure 15. Fischer AA. Reliability of the pressure algometer as a meas­ and should be applied only by those clinicians ure of myofascial trigger point sensitivity. Pain. 1987;28:411-4. whose state licenses permit such practice. 16. Fischer AA. Documentation of myofascial trigger points. True False Arch Phys Med Rehabil. 1988;69:286-9l. REFERENCES 17. Kraus H, Fischer AA. Diagnosis and treatment of myofas­ cial pain. Mt Sinai} Med. 1991;58:235-9. 1. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol 1. Baltimore, Md: Williams & 18. Gunn C. The Gunn Approach to the Treatment of Chronic Wilkins; 1983. Pain-Intramuscular Stimulation for Myofascial Pain of Radiculopathic Origin. London: Churchill Livingstone; 2. Hong CZ. Lidocaine injection versus dry needling to 1996. myofascial trigger point. The importance of the local twitch response. Am} Phys Med Rehabil. 1994;73:256-63. 19. Ingber R. Personal communication; 1991. 3. Hong CZ, Kuan TS, Chen JT, Chen SM. Referred pain 20. Ingber RS. Iliopsoas myofascial dysfunction: a treatable elicited by palpation and by needling of myofascial trigger cause of \"failed\" low back syndrome. Arch Phys Med Rehabil. 1989;70:382-6. 21. Ingber RS. Shoulder impingement in tennis/racquetball players treated with subscapularis myofascial treatments. Arch Phys Med Rehabil. 2000;81:679-82. 22. Ingber R. Myofascial Pain in Lumbar Dysfunction. Philadelphia, Pa: Hanley & Belfus Inc; 1999.

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Chapter 13 hen patients suffer from one or more of the fol­ and outer membranes covering the brain. Symptoms usually develop within a short period of time after a Wlowing conditions, trigger point and myofascial head injury. Manual therapy is very intense for such a therapy may be contraindicated: condition. * Malignancy: When a mass of cancer cells may invade * Anticoagulant therapy: Patients who are taking Coumadin (DuPont Pharmaceuticals, Wilmington, surrounding tissues or spread to distant areas of the Del) or heparin may develop bruises with the appli­ body. In general, manual therapy may be contraindi­ cation of trigger point therapy. Clearance from the cated depending on the type and area of the tumor. treating physician and consent from the patient * Open wounds in the area of application of trigger should be obtained before application of this tech­ point therapy. Tissue may become more irritated with nique. the application of trigger point therapy and myofas­ * Advanced osteoporosis: Bone loses calcium and phos­ cial stretching exercises. phorus, the minerals that make it strong. The tissue * Severe arteriosclerosis: Commonly shows its effects becomes less dense and bones become thinner. With first in the legs and feet. The arteries may become narrowed and blood flow decreases, progressing in sparse tissue or fewer supporting I beams, bones are some cases to total closure (occlusion) of the vessel. The vessel walls become less elastic and cannot dilate fragile and fracture easily. It is often called the silent to allow greater blood flow when needed. Excessive disease because fractures can occur without warning compression and stretching may cause blood clot for­ and when they are least expected. If trigger point mation. therapy and stretching exercises are too forceful, frac­ * Aneurysm: Resembles a sack of blood attached to one tures may occur. side of a blood vessel by a narrow neck. All types of manual therapy are contraindicated. Communication with the patient's primary care physician, * Subdural hematoma: A brain disorder involving a other treating physicians, as well as other clinicians involved in collection of blood in the space between the inner the patient's care is strongly suggested before /Jroceeding with treatment.

68 Chapter I 3 REVIEW QUESTIONS I . In what ways may trigger point and myofascial therapy be harmful to patients with severe advanced osteoporosis? A. Local hematoma B. Ineffective treatment C. D anger of fracture D. None of the above 2. A 50-year-old male is suffering from low back pain. Myofascial evaluation reveals active myofascial trig­ ger points on the quadratus lumborum. The patient is on Coumadin. What is the proper inter­ vention? A. Trigger point therapy will not help and should not be applied in this case. B. Obtain clearance from the physician and con­ sent from the patient before proceeding with treatment. C. Obtain clearance from the physician, consent from the patient, and proceed with treatment. Adjust pressure to avoid possible fracture. D. Obtain clearance from the physician, consent from the patient, and proceed with treatment. Adjust pressure to avoid bruising.

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Chapter 14 CHAPTER 1 12. Motor unit 13. True I. False 14. False 2. True 15. True 3. Postisometric relaxation CHAPTER 4 CHAPTER 2 1. False I. False 2. True 2. True 3. False 3. 71 4. Repetitive movements, high-velocity movements, 4. True 5. True stress positions 6. True 5. True 7. False 6. B CHAPTER 3 CHAPTER 5 I. False 1. False 2. False 2. False 3. Accessory 3. True 4. True 4. False 5. True 5. False 6. Actin 6. True 7. True 7. True 8. False 8. False 9. Triad 9. Positive stretch sign 10. False 10. B II. Motor endplate 11. C

72 Chapter 14 CHAPTER 1 0 CHAPTER 6 1. True 2. False I. True 3. False 2. False 4. False 3. False 5. True 6. False CHAPTER 7 7. True 8. True I. True 9. A 2. False 10. C 3. False 4. True CHAPTER 11 5. True 6. Central I. True 2. True CHAPTER 8 3. False 4. B j. False 2. True CHAPTER 12 3. True 1. True CHAPTER 9 2. False 3. True I. Patient pain recognition 4. False 2. False 5. True 3. False 6. True 4. Active, latent 5. False CHAPTER 1 3 6. True 7. True I. C 2. D

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Part B